1. sports
2. walking

Bull. Fac. Ph. Th. Cairo Univ., Vol. 16, No. (1) Jan. 2011
13
Impact of Arm Sling on Gait Pattern in Patients with Stroke:
A randomized Cross-over Study
Eman S Fayez, PT.D, and Abeer A.B El-Wishy, PT.D
Department for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt
ABSTRACT
Purpose: this study was designed to evaluate the
effect arm sling on temporal parameters of gait in
stroke patients. Methods: in a randomized, crossover study design twenty three stroke patients
diagnosed
as
cerebrovascular
accident
participated in the study. The patients were able to
walk independently and were in stage three or less
according to Brunnstrom stages of recovery for the
upper extremity. Three-dimensional gait data were
collected with the QUALISYS ProReflex motion
analysis system. Temporal parameters as: walking
velocity, cycle time, cadence, double-support time
and percentage of stance phase as well as
excursion of the center of gravity in the sagittal,
coronal, and transverse planes and finally the
excursion of the hip, knee, and ankle in the sagittal
plane were measured. Patients walked on a
walkway bare footed twice on the same day,
randomly with and without arm sling, at a selfselected speed. Results: when walking with sling,
patients showed an increase in the velocity; the
percentage of stance phase of the affected side and
a decrease in the double support time which were
statistically significant. In addition, excursion of
the center of gravity decreased in all planes.
Conclusions: during gait training sessions it is
recommended that patients with stroke wore arm
sling to improve gait pattern.
INTRODUCTION
S
ubluxation of the shoulder has been
associated with numerous negative
outcomes including electromyographic
findings consistent with denervation in the
affected upper limb1. Chino reported delayed
latency times, with the most notable slowing
being in the suprascapular and axillary
nerves2. This early traction neuropathy can
result in a transient nerve injury that delays
rehabilitative and functional progress by
months1 or can become a long-term injury that
is resistant to treatment3. The subluxated
position of the humerus may also contribute to
the pathogenesis of other conditions by
stretching neurovascular and musculoskeletal
tissues around the shoulder joint4. These
conditions include limited range of motion,
pain, brachial plexus injury, reflex sympathetic
dystrophy, adhesive changes, and subacromial
impingement among others5,6. In addition,
subluxation is related to poorer motor return in
the upper limb6. All of these conditions can
significantly affect a patient’s physical,
functional, and psychosocial rehabilitation7.
However, the positioning of the arm
produced by a sling not only interferes with
functional activities but also enhances the
flexor synergy of the upper extremity8. In
patients with hemiplegia, gait problems such
as poor gait performance, reduced walking
endurance and decreased functional mobility
are some of the more serious disabilities9. In
addition, Bohannon et al.,10 reported that most
stroke patients rank the restoration of walking
in the community as one of the most important
goals of rehabilitation.
This study was designed to investigate
the effect of an arm sling on gait patterns of
patients with stroke.
METHODS
Participants
Twenty three patients with stroke were
recruited to this study. Inclusion criteria for the
patients were (1) first episode of
cerebrovascular accident verified clinically
and radiologically by computed tomography or
magnetic resonance imaging, (2) ability to
understand and follow commands, (3)
ambulatory before stroke, (4) no medical
contraindication to walking, (5) Brunnstrom
stages of recovery11 for the upper extremity≤ 3
and (6) ability to walk independently. All
subjects provided written informed consent
before data collection.
All patients wore a vest-type shoulder
forearm support during the gait trials. The
vest-type shoulder forearm support was
designed and turned out to prevent
glenohumeral subluxation and stabilize the
shoulder joint more effectively than a Bobath
sling or single strap12.
Impact of Arm Sling on Gait Pattern in Patients with
Stroke: A randomized Cross-over Study
14
All the patients walked on a walkway
bare footed twice on the same day, randomly
with and without arm sling, at a self-selected
speed. Individuals assigned odd numbers
walked without the arm sling first and vice
versa for those given even numbers.
The walking patterns of the subjects
were captured and analyzed by QUALISYS
ProReflex motion analysis system. This
system included: six camera system, wand-kit
used for calibration of the system and PC
computer with the Q-Trac software installed.
Patients were instructed to walk at a self
selected speed over a 10-meter walkway.
Fifteen lightweight retro-reflective markers
were attached to the skin over the following
bony landmarks: sacrum, bilateral anterior
superior iliac spine, middle thigh, lateral knee
(directly lateral to axis of rotation), middle
shank (the middle point between the knee
marker and the lateral malleolus), lateral
malleolus, heel, and forefoot between the
second and third metatarsal head13. The mean
of three trials was used in analysis. Temporal
parameters as walking velocity, cycle time,
cadence, double-support time, and percentage
of stance phase; joint rotation angles of pelvis
in sagittal, coronal, and transverse planes and
excursion of hip, knee, and ankle in sagittal
plane. Data were processed by using Q-Trace
software.
Data Analysis
Data analysis was performed by using
SPSS for Windows version 8.0. Data are
presented as mean ±standard deviation (SD).
Comparisons of the variables was done using
the paired t test for temporal parameters:
walking velocity, percentage of stance phase,
cycle time, cadence and double-support time;
joint rotation angles of pelvis in sagittal,
coronal and transverse planes and excursion of
hip, knee, and ankle in sagittal plane with and
without an arm sling. Statistical significance
was accepted at a P level < 0.05.
RESULTS
As presented in table 1 the mean age was
55.1±9.3 years. Mean height and weight were
162.9± 8 cm and 87±6.9 kgm respectively.
Fifteen patients were males and eight patients
were females. For the side stroke eleven were
right sided and twelve were left sided stroke.
Time since stroke was 58.2±13.8 days. Eight
patients were in stage I, twelve patients were
in stage II and three patients were in stage III
according to Brunnstrom stages of recovery
for the upper extremity.
Table (1): General characteristics of patients.
Parameters
Age (mean ± SD)
Gender
Male
Female
Height
Weight
Side of stroke
Right sided
Left sided
Time since stroke (mean ± SD)
55.1±9.3 years
15
8
162.9±8 cm
87±6.9 kgm
Numbers of patients according to Brunnstrom stages of recovery for the upper extremity
11
12
58.2±13.8 days
Eight patients in stage I
Twelve patients in stage II
three patients in stage III
Table (2): Temporal parameters of gait with and without the arm sling.
Temporal parameters of gait
Walking velocity (meter/second)
percentage of stance phase (affected side)
Cycle time(seconds)
Cadence (number of steps per minute)
Double support time (seconds)
*Significant at P≤0.05
Without arm sling
.34±.13
51.4 ±3.6
.24±4.1
71.3±5.7
1.08±.09
With arm sling
.45±.14
57.9±4.1
.27±2.8
79.3±3.9
.67±.03
P value
.036*
.021*
.645
.001*
.043*
Bull. Fac. Ph. Th. Cairo Univ., Vol. 16, No. (1) Jan. 2011
Inspection of table 2 and figure 1,2 and 3
revealed that there was significant increase of
walking velocity, percentage of stance phase
and cadence whereas there was significant
15
decrease in double support time as P was ≤
0.05. Alternatively, there was no significant
difference for cycle time (P=0.645) with the
use of arm sling.
Cycle time (sec.)
Double support time (sec.)
1.2
1
0.8
0.6
0.4
0.2
0
Without arm sling
With arm sling
Fig. (1): Mean values of cycle time and double support time (seconds) with and without arm sling.
Cadence (number of steps per minute)
80
78
76
74
72
70
68
66
Without arm sling
With arm sling
Fig. (2): Mean values of cadence (number of steps per minute) with and without arm sling.
Percentage of stance phase (affected side)
58
56
54
52
50
48
Without arm sling
With arm sling
Fig. (3): Mean values of percentage of stance phase with and without arm sling.
Mean values of pelvic excursion without
arm sling were 11.7±4.5, 9.6±3.5 and 12.2±7.4
for sagittal, coronal and transverse plane
respectively then decreased to 9.8±4.1, 8.7±2.9
and 10.43±6.4 with the use of arm sling. This
decrease was significant as p was≤0.05. There
was no significant difference for hip, knee and
ankle excursion values with the use of arm
sling. (Table 3 and figure 4)
Impact of Arm Sling on Gait Pattern in Patients with
Stroke: A randomized Cross-over Study
16
Table (3): Pelvic excursion in sagittal, coronal and transverse plane and hip, knee and ankle excursion in
sagittal plane.
Gait parameters
Pelvic excursion in
sagittal plane(degrees)
Pelvic excursion in
coronal plane (degrees)
Pelvic excursion in
transverse plane(degrees)
Hip excursion (degrees)
Knee excursion (degrees)
Ankle excursion (degrees)
*Significant at P≤0.05
Without arm sling
With arm sling
P value
11.7±4.5
9.8±4.1
.017*
9.6±3.5
8.7±2.9
.001*
12.2±7.4
10.43±6.4
.011*
22.6±9.3
25.6±13.5
12.5±9.5
22.9±9.0
25.5±12.0
12.7±5.5
.975
.950
.929
Without arm sling
With arm sling
14
12
10
8
6
4
2
0
Pelvic exursion in segittal
plane (degrees)
Pelvic exursion in coronal
plane (degrees)
Pelvic exursion in transverse
plane (degrees)
Fig. (4): Mean values of pelvic excursion (degrees) in sagittal, coronal and transverse plane with and
without arm sling.
DISCUSSION
When walking with a sling, the stroke
patients showed an increase in the velocity and
the percentage of stance phase of the paretic
side and a decrease in the double support time,
which were statistically significant. With the
application of the arm sling, excursion of the
(center of gravity) COG was decreased in all
planes.
Arm slings are still the most preferred
treatment for shoulder subluxation in stroke
patients14. The gait of hemiplegic patients with
stroke is characterized by asymmetry in stride
times and stride length, slow velocity, poor
joint and posture control, muscle weakness,
abnormal muscle tone and abnormal muscle
activation patterns, mostly affecting the paretic
side15,16. Restoration of normal movements of
the trunk, pelvis, and lower extremity while
walking; increasing the walking speed; and
improved weight bearing on the paretic side
are the most important goals of gait training in
stroke patients16,17. In this study, with the
application of an arm sling, walking speed and
the percentage of stance period increased,
double support time of the paretic side and the
excursion of COG decreased.
Gait speed has a crucial effect on
independence in patients with hemiplegia and
may vary depending on the authors, but has
mostly been reported to be 25–40 m/min.18,19
Robinett and Vondron reported that gait speed
enabling independent activities of daily living
(ADL) in healthy people averaged 44.5
m/min. 20 In this study walking velocity
increased from .34 to .45m/sec. after using
arm sling.
In
patients
with
stroke,
gait
rehabilitation, including increase of gait speed,
is essential for the performance of independent
ADL. Therefore, the result of the present study
suggests that an arm sling may be a useful
modalitiy in gait rehabilitation.
Clarification for the positive effects of
the use of an arm sling on gait could be
attributed to the following; because hemiplegic
patients with an impaired body image are
unaware of the location of their body weight
line and they do not have any sense of
instability, they fail to make any postural
adjustments so the arm sling may serve as a
Bull. Fac. Ph. Th. Cairo Univ., Vol. 16, No. (1) Jan. 2011
feedback tool and remind the patient's arm to
help postural adjustments. Likewise it may
help hemiparetic patients with attention deficit
or neglect pay more attention and position the
paretic arm correctly8.
Minimizing the displacement of the
body's COG from the line of progression is a
significant way to reduce the muscular effort
of walking and, consequently, to save energy.
Through a mixture of six motion patterns,
called determinants of gait, the magnitude of
vertical and horizontal displacements is
reduced. In addition, abrupt changes in
direction are avoided, which is another energysaving maneuver. Pelvic motion in the three
planes smoothes the path of the body's vertical
travel and saves energy21. It has been shown
that patients with hemiplegia display excessive
excursion of the COG, which indicates the
inefficiency of their gait22. The total excursion
of the COG in sagittal, coronal, and transverse
planes was investigated in current study and
found a statistically significant decrease in the
excursion of the COG when arm sling was
used, indicating a more efficient gait.
Some investigators evaluated the effect
of restricted arm swing in healthy subjects.
Marks stated that restricted arm swing worsen
kinematics for efficient locomotion in healthy
adults23. Ford et al., found that constraining
one arm increases the arm swing on the
opposite side in order to maintain the
coordination between upper and lower body
movement24. Moreover the authors stated that
reduced arm swing might affect walking in
healthy adults. In the current study excursion
of the centre of gravity decreased with the use
of an arm sling. In contrast to the
aforementioned studies, gait improved with
use of an arm sling in the current study. The
discrepancy may be a consequence of the
study groups' characteristics. In healthy
subjects, upper extremity muscle activity is not
affected in contrast to patients with hemiplegia
who have both upper and lower extremity
impairments. Patients with hemiplegia may
have different interactions and adaptations,
unlike healthy subjects.
Although arm sling interferes with
functional activities and enhances the flexor
synergy of the upper extremity it seems to
17
affect positively the stability and efficiency of
walking.
Conclusion
Among other interventions, an arm sling
can be applied to improve gait pattern,
especially during gait training sessions.
REFERENCES
1- Kaplan, P.E., Meridith, J., Taft, G. and
Betts, H.B.: Stroke and brachial plexus injury
(a difficult problem). Arch Phys Med Rehabil;
58: 415-418, 1997.
2- Chino, N.: Electrophysiological investigation
of shoulder subluxation in hemiplegics. Scand
J Rehabil Med; 13: 17-21, 1981.
3- Wang, R.Y.,
Chan, R.C.
and
Tsai, M.W.: Functional electrical stimulation
on chronic and acute hemiplegic shoulder
subluxation. Am J Phys Med Rehabil; 79: 383390, 2000.
4- Vuagnat, H. and Chantraine, A.: Shoulder pain
in hemiplegia revisited (contribution of
functional electrical stimulation and other
therapies). Rehabil Med; 35: 49-56, 2003.
5- Ikai, T., Tei, K., Yoshida, K., Miyano, S. and
Yonemoto, K.: Evaluation and treatment of
shoulder
subluxation
in
hemiplegia
(relationship
between
subluxation
and
pain). Am J Phys Med Rehabil; 77: 421-426,
1998.
6- Lo, S., Chen, S., Lin, H., Jim, Y., Meng, N.
and Kao, M.: Arthrographic and clinical
findings in patients with hemiplegic shoulder
pain .Arch Phys Med Rehabil; 84: 1786-1791,
2003.
7- Hayes, K.W. and Sullivan, J.E.: Reliability of a
new device used to measure shoulder
subluxation. Phys Ther; 69: 762-767, 1989.
8- Faghri, P.D., Rodgers, M.M., Glaser, R.M.,
Bors, J.G., Ho, C. and Akuthota, P.: The
effects of functional electrical stimulation on
shoulder subluxation, arm function recovery,
and shoulder pain in hemiplegic stroke
patients. Arch Phys Med Rehabil; 75: 73-79,
1994.
9- Hesse, S.: Rehabilitation of gait after stroke:
evaluation, principles of therapy, novel
treatment approaches and assistive devices.
Top Geriatr Rehabil; 19: 111-131, 2003.
10- Bohannon, R.W., Andrews, A.W. and Smith,
M.B.: Rehabilitation goals of patients with
hemiplegia. Int J Rehabil Res; 11: 181-182,
1988.
18
Impact of Arm Sling on Gait Pattern in Patients with
Stroke: A randomized Cross-over Study
11- Sawner, K. and Lavigne, J.: Brunnstrom's
movement
therapy
in
hemiplegia:a
neurophysiological
approach.
2nd
ed.
Philadelphia: JBLippincott; 41-65, 1992.
12- Kang, W., Seo, W.H., Yu, J.Y. and Ha, S.B.:
Newly designed vest-type shoulder forearm
support for the subluxated shoulder. J Korean
Acad Rehabil Med; 20: 787-793, 1996.
13- De Quervain, I.A., Simon, S.R., Leurgans, S.,
Pease, W.S. and McAllister, D.: Gait pattern in
the early recovery period after stroke. J Bone
Joint Surg Am; 78: 1506-1514, 1996.
14- Chantraine, A., Baribeault, A., Uebelhart, D.
and Gremion, G.: Shoulder pain and
dysfunction in hemiplegia: effects of functional
electrical stimulation. Arch Phys Med Rehabil;
80: 328-331, 1999.
15- De Quervain, I.A., Simon, S.R., Leurgans, S.,
Pease, W.S. and McAllister, D.: Gait pattern in
the early recovery period after stroke. J Bone
Joint Surg Am; 78: 1506-1514, 1996.
16- Thaut, M.H., McIntosh, G.C. and Rice, R.R.:
Rhythmic facilitation of gait training in
hemiparetic stroke rehabilitation. J Neurol Sci;
151: 207-212, 1997.
17- Tyson, S.F.: Trunk kinematics in hemiplegic
gait and the effect of walking aids. Clin
Rehabil; 13: 295-300, 1999.
18- Skilbeck, C.E., Wade, D.T., Hewer, R.L. and
Wood, V.A.: Recovery after stroke. J Neurosur
Psychiatry, 46: 5-8, 1983.
19- Wade, D.T., Wood, V.A., Heller, A., Maggs,
T. and Hewer, R.L.: Walking after stroke.
Measurement and recovery over the first 3
months. Scand J Rehabil Med; 19: 25-30,
1987.
20- Robinett, C.S. and Vondran, M.A.: Functional
ambulation velocity and distance requirements
in rural and urban communities. Phys Ther; 68:
1371-1373, 1988.
21- Perry, J.: Gait analysis: normal and
pathological function. Thorofare (NJ): Slack;
1992.
22- Adams, J.M. and Perry, J.: Gait analysis:
clinical application. In: Rose J,Gamble JG,
editors. Human walking. 2nd ed. Baltimore:
Williams& Wilkins; 139-164, 1994.
23- Marks, R.: The effect of restricting arm swing
during normal locomotion. Biomed Sci
Instrum; 33: 209-215, 1997.
24- Ford, M.P., Wagenaar, R.C. and Newell, K.M.:
Arm constraint and walking in healthy adults.
Gait and Posture; 26: 135-141, 2007.
‫الملخص العربي‬
‫ دراسه عشوائيه‬: ‫تأثير حمالة الذراع على كفاءه المشي في المرضى المصابين بالجلطه الدماغيه‬
ً‫ جمٌع المرضى كانت لدٌهم القدره على المشً بدون مساعده وف‬. ‫اجرٌت هذه الدراسه على ثالثه وعشرون مرٌض بالسكته الدماغً ة‬
‫ قام المرضى بالمشً على‬. ً‫ تم عمل التحلٌل ثالثً االبعاد للمش‬. ‫المرحله الثالثه او اقل طبقا لمراحل برنستورم لشفاء الطرف العلوي‬
‫ اظهرت النتائج زٌاده‬. ‫لمناسب لهم وعشوائٌا مره بدون حماله الذراع ومره اخرى بها‬
‫ة‬
‫الممر بدون حذاء مرتٌن خالل نفس الٌوم بالسرعه ا‬
. ً‫الجلس الخاصة بتأهٌل المش‬
‫ة‬
‫حمال الذراع خصوصا اثناء‬
‫ة‬
‫الدراس باستخدام‬
‫ة‬
‫ توصً هذه‬. ‫الدقٌق‬
‫ة‬
ً‫كبٌره فً المشً وعدد الخطوات ف‬